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Home My WebLink AboutMEADOW BROOK BLK 2 LT 12Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211149 PID Number: 050 191 59 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name BAHNEMAN ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 18319 KARTA ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot MEADOW BROOK B2 L12 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well - _ _ _ _ TANK Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water +100 _ _ Material Number of compartments Lot Line +5 _ _ NA PLASTIC 2 Foundation 6 _ _ LIFT STATION Manufacturer Capacity Remarks TANK ONLY - _ Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to drainfield 3034 Installer NORTHERN Drainfield CO/MT 3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspec2�dion 151 5/26/21 6/4/21 Location and description dates: top of tank lid 3rd 4'h ON-SITE WATER AND WASTEWATER SECTION APPROVAL 2/19/21 Engineer's Stamp OF A`qS� Conditional Approval: Date 'low,~� *: 49 TH •. * r . . r • Septic System r CHARLES G BALZARINI �%�F• Date I CE-13854 Aw r ll,F�pROFESS10NP4� Note: this approval does not include well permit requirements. (Rev u5iuuiu) LEGEND 70 CLEANOUT MONITOR TUBE SWING TIES LEGAL DESCRIPTION:MEADOW BROOK B2 L12 OWNER:BAHNEMAN DATE: 6/9/21 REV: 0 1 DRAWN: CB I REF: A B C 11.26 19 D 15.1 23.6 E 16.1 24.8 '17.7 26.4 GI 33.5 41.1 t W, .. ........ 49TM •. �CHARLES G BALZARINI / � �'��•. CE•13854 .•��`�'�� 1%hp • • , 6/9/21 • �� PROFESSIONP-A=� N -:\W 1000 GAL\POLY TANK\ - NEW DIAL CLEANOI0�S DRIVEWA APPROX. \� RIBOGEXIST CRIB- OG PSE i i i G 100 99.8 3 \ 4'COVER BTM FOOTING 1000 GAL POLY TANK 45 -DEG SOIL /\ BEARING LINE 95.2 EMATIC SETCION, NTS APPROX. WATERLINE SCALE: 1" = 20' C&M ENGINEERING SERVICES 907-854-5558 LEGAL DESCRIPTION:MEADOW BROOK B2 L12 OWNER:BAHNEMAN DATE: 6/9/21 REV: 0 1 DRAWN: CB I REF: SITE PLAN Q w c rn 2 `p 4d/J 1lrf o c a o m w ! Sp /r w z zx Oo L/ = O Q w CO 0 U N 6/ H Q W w q:�i > (n0� z mu :ch co O o� >- D ��} Q iLL. N �i W m QW~ �- i !: � U) ivy �m o J cn� p �w0 No / 9Z /ice'• C»: Q�� >a O ova `l' o rr� S �5��fit =a c90� M Q U N J 9016 X / y 5�a �� oZo Q� 5y`"`N y v� Wo v W > cifWW W NZLO F- W � �Z m ��Z = r za 2a�o U= Va _CA Co w� O�Z DYw gym` Q c(i•i W z cA W_ J Z= O ~Q a w /� 3 N �U �N Z \ Ow OJ QF - U) 0Q IL I -i C'41 x k �� O � co/ \ pz Q m Cl) sllIn LU -1 cr)\� OZ U)z Qo U ON ydU:" Z� W� ¢z CO ow x r 20, 2 00 -� 0O co ZO =w ps`O` `9 w0 O� �O y \ InZ mQ 0(L 0 > p W Q d � tE o�oo ��' 1�2a1 ZQ S= Quill _ F- 0po s23�,E M �ti ZW OWo W \w o =� oQ �� c�Q F- j U) 00 W 0W OaOU wzm z U U > vF-~F-cn OO Qui z—�- O o z W> O Z U � 0 Z F- < m F- Q Co U U) d zam O� w0� �ZCD U) o r0 �~ Q UC) co W z zW UU: p� rn F- w O O p w 0 p w} z 0 L o_ 0 S W 0 U m> w Wo m N (n F<- < Q W 1: ZD) �ZU)U) m W 0� F -U)() ADW O n MUNICIPALITY OF ANCHORAGE On-Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On-Site Wastewater Disposal System Permit Permit Number: OSP211149 Work Type: SepticTank Upgrade Tax Code Number: 05019159000 Site Legal Address: MEADOW BROOK BLK 2 LT 12 G:0153 Site Mailing Address: 18319 KARTA CIR, Eagle River Effective Date: Expiration Date: ;-,en � ;.. C.,1��("> C) ·n ,.., I ,, �" . V. Department 5/18/2021 5/18/2022 Owner: ANAL OAK HOLLY M 50% & Lot Size in Sq Ft: 15276 3 Design Engineer: C&M ENGINEERING SERVICES This permit is for the construction of: □Disposal Field 0 Septic Tank D Holding Tank D Privy All construction shall be in accordance with: 1.The attached approved design. Total Bedrooms: D Private Well D Water Storage 2.All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3.The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4.From October 15 to April 15, _a subsurface soil absorption system under construction during freezing weather shall be either: a.Opened and Closed on the same day, or b.Covered, sealed, and heated to prevent freezing Special Provisions: ** Prior to construction, confirm that the water line location shown on the proposed plan view is correct. If the water line location requires a design change, construction of the system will stop pending On-Site review and approval. Show the located water line on the record drawings. Received By: .r,,,;, /. � Issued By: XJ,,,11/ VI/ � Date: Date: C&M ENGINEERING 5/20/21 MUNICIPALITY OF ANCHORAGE ci Development Services Department ``' Phone: 907-343-7904 On -Site Water & Wastewater Section -- Fax: 907-343-7997 ON-SITE SEPTICNVELL PERMIT APPLICATION Parcel I.D. 050 191 59 Property owner(s) Chris Bahneman Mailing address Site address 18319 Karta Day phone Legal description (Sub'd., Block & Lot) Meadow Brook Block 2 Lot 12 Legal description (Township, Range & Section) Lot Size 15,276 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade Duplex ❑ (D) Holding Tank ElRenewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees: 2 2 Date of Payment: —-5/17 0202 / Receipt Number: O g -24o6 Permit No. 0510 21)1 4 cl Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System Modification for Meadowbrook Block 2 Lot 12 Dear Reviewer, The above referenced property is currently served by a 3 bedroom septic system installed in 1970s. The Tank is over 30-years old and is need of immediate replacement. We are proposing that the existing tank be replaced with a new 1000 gallon moa approved septic tank. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of 4’ of cover without insulation. The repair must be performed by a moa certified installer in accordance with MOA requirements. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 5/10/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211149, Deb Wockenfuss, 05/18/21 ASBUILT I HEREBY CERTIFY -THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: ~~ ,&(7~~ -<c?£ ..,c'~/~ ~ z ANO THAT NO ENCROACHM~TS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSJ!31LITY OF THE OWNER TO DETERMINE THE ~CISTENCE OF ANY EASEMENTS, COVENANTS) OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES S..au> ANY DATA HEREON BE USED FOR . CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. SEWARD & ASSOCIATES LAND SURVEYING 6 9 4-0 8 2 g SCALE: //~ ;?/?I 0~~~~6 ANCHORAGE AREA BOr ' Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM PHONE LOCATION SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER INSIDE WIDTH NUMBER OF · COMPARTMENTS LIQUID DEPTH_ __.LIQUID CAPACITY /'~)~<~) GALLONS, SEEPAGE PIT: NUMBER OF PITS LINING MATERIAL BUILDING FOUNDATION _'.~ ~ ADDITIONAL ABSORPTION DIAMETER ~gO' OR WIDTH /-~', LENGTH_/.~'/, DEPTH CRIB SIZE: DIAMETER DEPTH ~¢ DISTANCE FROM: WELL TOTAL EFFECTIVE NEAREST LOT LINE__ ABSORPTION AREA (WALL AREA) .SQ. FT. WELL: TYPE ~ Olx~lk~, U k', L~ BUILDING FOUNDATION __ CESSPOOL APPROVED __ CONSTRUCTION NEAREST -- --, LOT LINE · , OTHER SOURCES - DISAPPROVED DEPTH DISTANCE FROM: NEAREST SEPTIC SEEPAGE SEWER LINE , TANK. , SYSTEM REMARKS_ DISTANCES: DIAGRAM OF SYSTEM INSTALLED BY: PIPE MATERIAl , LOT SLOPE: REMAR~.(S: Forrn NO. EQ-031 MUNIMPALITY OF TYPE OF WASTEWATER DISPOSAL: Private Well L1 Private Septic Water Storage ❑ Development Services Department r On -Site Water & Wastewater Section Parcel I.D. 050 191 59 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: q, 2-� Complete legal description Meadow Brook Block 2 Lot 12 Location (site address) 18319 Karta Current property owner(s) Chris Bahneman Day phone Mailing address Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well L1 Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System Public Sewer ❑ Waiver request for: NONE Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55v Date of Payment (� 1 Receipt Number 2 COSA# QSC ),1131 1 Waiver Fee $ Date of Payment Receipt Number Waiver # STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm C&M ENGINEERING Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Phone 8545558 Date 6/1/21 OF A/- k ,. co *: 49TH * / i• I IJ .�• �-- H • CHARLES G BALZAR191 r�� F••, CE -13854 .••c`�� liF� pROFE5S10NP�.� Conditional approval for bedrooms, with the following stipulations: �J CN -SITE �y AND �o WN m P S'Tf-1 ; -rr-,. o ROGRAM �LZRV?rn� Original Certificate Date: � _1 —Z The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: MEADOW BROOK B2 L12 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments NO WELL B. TANK DATA Age of tank(s) 0 years Tank type/material SEPTIC PLASTIC Measured operating fluid level in septic tank NA ❑ Standpipes/foundation cleanout per record drawing Date of pumping NA -NEW TANK D. ABSORPTION FIELD DATA CRIB Which system tested (date installed) 1974 ❑ ALL standpipes present per record drawing Total measured depth from grade 10 ft (max) Measured depth to pipe invert from grade NA ft (min) ❑ N/A — pr assti-r ze&fi-iti — ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: NONE, CRIB CO REPAIRED COSA Checklist yellow sheet Parcel ID: Structure served by this system 1 nen i qi _r;q Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ON N ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Date of Sample C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/4/21 Results IDPass For 3 bedrooms Fluid depth prior to test 24 in Water added 450 gal New depth 25 in Elapsed time 10 min Final fluid depth 24 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date NA E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No 6 Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No ft Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' Water Main > 10'✓❑ if No Animal Containment > 50' ❑ Yes if No ft ❑ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No 6 ft Surface Water > 100' Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓❑ Absorption Field > 5'✓❑ Yes Yes if No ft Private Wells > 100'✓❑ Yes if No ft Water Main > 10'✓❑ if No Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓❑ Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100'✓❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 6/9/21 COSA Checklist yellow sheet 'CT! OF A`,4 4 - TM '• j CHARLES G BALZARINI �� . • CE -13854 � �F�PROFESSO MUNICIPALITY OF ANCHORAGE WATER CONNECTION – Location Record ACCT. NO. 0,-) L7)0 NAME 'R3 [AIRE$g— LOT BLOCK ADDITION (9m ggoo� li SIZE CONN. DATE MADE NEW CONN. REPLACEMENT CONN. LOCATION: ALLEY ❑ STREET ❑ TYPE OF MAIN I I SHOW SKETCH ON REVERSE SIDE CORP STOP THAW PLATE PERMIT NO. CURB STOP C TO C KEARNY WIRE CONNECTOR W. CURB STOP C TO I OTHER: CONN. CORP CONNECTOR INSP. COUPLING C TO I PERMIT X BRASS BUSHING TOTAL X GALVANIZED BUSHING COMMENTS: BROKEN MAIN, EXT. CONNECTION, EXTRA PIPE 2 PART UNION CASING, DELAYS, ETC. FT. @ 3 PART UNION PILA SERVICE CLAMP X 0 PAID PR EV. COPPER PIPE CD W.M. # 1 1/4" KEY BOX ❑ PAID CASH 2" KEY BOX ❑ SUB AGREEMENT THAW WIRE DISCONNECTS ALT. # — LOCATION ze EXCAVATOR CD IMP. DIST. -S/06 APPOINTMENT TIME: # TIME READY: ❑ EXT. AGREEMENT CONNECTION MADE BY INSPECTED BY # 31-058 (12/77) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICA-r'E OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1, GENERAL INFORMATION Complete legal description Lot 12; Block 2; Meadow Brook Subdivision Location (site address or directions) 18318 Karta Drive Property owner Mailing address Ralph Zieglmeier Day phone , 694-3950 Lending agency Mailing address Day phone Agent Laura Hamilton GREATLAND REALTY 11411 01d Glenn Highway Address F~g.Ca ~Jue/r; Al~ba 99577 Unless otherwiso requosted, HAA will bo held for pickup. 2. NUMBER OF BEDROOMS: 3 ",4 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: ...lng to the legality and status of system. 4. TYPE OF WASTEWA'I'ER DISPOSAL: Individual on-site XX Holding tank Community on-site NOTE: Day phone 694-9125 'N If community well system, provide written confirmation from State ADEC attest- Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1191) From MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & S ENGINEERING 17034 Eagle River Loop Road No. 204 ~l~ i?[vm', AIn~'n ?_0~7~' DHHS SIGNATURE Approved for bedrooms. Phone Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By:~' ~~¢'~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) 8ack MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: [,--~'~' \'/,' ¢-~-¢- 'Z-- l,.~¢,~b,~,,,.L ~¢-~ov..~(f!~trcel I.D. Well type L--/.~X:: If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date completed Driller Cased to Casing height_ Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ¢.-o~ Absorption field on lot '2.0o ~ Public sewer main Sewer service line g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B, SEPTIC/HOLDING TANK DATA Date installed '~ Nitrate Other bacteria Collected by: Tank size \OE)O ~/,¢t~ Compartments Cleanouts (~N) ? Foundation cleanout (~/N) ',/ Depression (Y~) High water alarm (Y~_/~ ~ Alarm tested (Y/N) Date of pumping 5"- ~ ~ -~ ?.-- Pumper Well(s) on lot_ 7'0 property line 1 Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ~I~ On adjacent lots , .k Absorption field / ~' Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ycles tested Meets MOA electrical codes (Y/N)_/ .,.T T^T.O, TO: 3Neff~dn lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~ off" level at Surface water D. ABSORPTION FIELD DATA Date installed ~ ~"/~' Soil rating Length~ /5' J k~ , Width t %' Gravel thickness~ Total absorption area Depression over field (Y/~) Results ~fail) /9¢~$ for Peroxide treatment (past 12 months) (Y~J~ ~System type ~f~44 ¢ Total depth ~,~ ' SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot '2,~¢ To building foundation On adjacent lots Surface water Curtain drain /J,/~ Cleanouts present Date of adequacy test If yes, give date ~'/.,~ On adjacent lots 'J/,"~ Property line To existing or abandoned system on lot Cutbank ~J~- Water main/service line Driveway, parking/vehicle storage area bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on date of this inspection. S & $ ENGINEERING Signature ! '/0_~4 i:;~wjl,~ t'H,~,~:. I Eagle Pdvet', Alaska Engineer's Name Date HAA Fee $ /7~), '~ Date of Payment -~- ~-[ ~7' ,~ Receipt Number 72-026 (Rev, 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ' DAZI' E RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR ~ ~UNICIPALITY OF ANCHORAGE RUNIClPALII'Y OF ANCHORAGE DEPT, OF I!:'~Llll & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT~NMENTAL P~OTECI'ION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION - ' Telephone 264-4720 DIR[~TION~: OompJete all parts o,, page 1. I~m~pl.t~ r.qu.sts will ~ot b~ pro~ss~J. Please allow ten (10)days for PROPERTY RESIDENT (If different from above) PHONE 2. BUYER ~ ~ PHONE MAILING ADDRESS 3. LENDING ~TITUTION PHONE MAILING 5. LEGAL DESCRIPTION /.cT' l:z STREET LOCATION 6. TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOM8 [] One [] Four [] Two [] Five Three [] Six [] Other 7, WATER SUPPLY [] INDIVIDUAL* ' ~OMMUNITY UBLIC UTILITY * ATTACH WELL LOG, A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~] INDIVIDUAL/ON-SITE ' [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED, ... NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-O10 (Rev. 6179):(~.~.~..~/z' ~.-/.~d2.~-4---] ~' ~ THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] S~X PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: 14¢~")(:~~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS U A PROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79)